Vacation Bible School | Episcopal Church in Purceville, Virginia

Parent Contact Details

Name(Required)

First Last

Email(Required)

Contact Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Church Regularly Attended, if any

Student Details

Child's Name(Required)

First Last

Name Child goes by(Required)

Date of Birth(Required)

Rising Grade(Required)

Gender(Required)

Health Insurance Company(Required)

Health Insurance Policy or Group Numbe(Required)

Doctor's Name(Required)

Doctor's Phone(Required)

Dentist's Name(Required)

Dentist's Phone(Required)

Explain any other special medical concerns, including allergies, such as to foods or to medications. Also list any medications currently used.

Any other information we should be aware of?

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Contact Phone(Required)

Person other than listed parents authorized to pick up child

First Last

Relationship

Contact Phone

Photo Release & Confirmation

My child may be photographed during VBS(Required)

By entering my name below and clicking submit, I am certifying that the information on this form is correct and that I am legally responsible for the child listed here. I further agree that the child has my permission to participate in St. Peter's VBS program and I understand that a donation of $25 per child or $30 per family is required, payable on the first day of VBS, cash or check only. I do also hereby authorize adult volunteers of St. Peter's Episcopal Church as agent(s) on my behalf to consent to any medical care deemed advisable by any accredited physician in an approved emergency clinic or hospital. I further release from any liability St. Peter's Episcopal Church, any of its ministries or leaders in the event of an accident en route, during and returning from Vacation Bible School.

Signed(Required)

Phone

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